(2) Criteria that the Secretary shall adopt by regulation for determining
the appropriate level of investigation for a complaint concerning quality of care,
including:

(i) A determination as to whether the member or subscriber with
the complaint previously attempted to have the complaint resolved; and

(ii) A determination as to whether a complaint should be sent to the
member's or subscriber's health maintenance organization for resolution prior to
investigation under the provisions of this section; and

(3) A procedure for the referral of quality of care complaints to the
Secretary for an appropriate investigation.

(c) If a determination is made to investigate a complaint under the provisions
of this section prior to the member or subscriber attempting to otherwise resolve the
complaint, the reasons for that determination shall be documented.

(d) Notice of the complaint system established under the provisions of this
section shall be included in all contracts between a health maintenance organization
and a member or subscriber of a health maintenance organization.

(e) For quality of care complaints referred to the Secretary for investigation
under subsection (b)(3) of this section, the Secretary shall report to the Commissioner
in a timely manner on the results and findings of each investigation.

19-705.8.

(A) (1) IN THIS SECTION THE FOLLOWING WORDS HAVE THE MEANINGS
INDICATED.

(2) "HMO QUALITY ASSURANCE UNIT" MEANS THE HEALTH
MAINTENANCE ORGANIZATION (HMO) QUALITY ASSURANCE UNIT IN THE
DEPARTMENT.

(3) "QUALITY ASSURANCE MEDICAL DIRECTOR" MEANS THE MEDICAL
DIRECTOR OF THE HMO QUALITY ASSURANCE UNIT.

(B) THERE IS A HEALTH MAINTENANCE ORGANIZATION (HMO) QUALITY
ASSURANCE UNIT IN THE DEPARTMENT.

(C) (1) THE SECRETARY SHALL APPOINT THE QUALITY ASSURANCE
MEDICAL DIRECTOR

(2) THE QUALITY ASSURANCE MEDICAL DIRECTOR SHALL:

(I) BE A PHYSICIAN WHO IS LICENSED IN THE STATE;

(II) BE BOARD CERTIFIED IN AT LEAST ONE SPECIALTY;

(III) HAVE EXPERIENCE IN PRIMARY CARE AND ADMINISTRATIVE

MEDICINE; AND